Homepage | PNCB
|DOCUMENTATION OF PNP EDUCATION FORM |
|PEDIATRIC NURSING CERTIFICATION BOARD |
|9605 Medical Center Drive, Suite 250 |
|Rockville, MD 20850 |
|1-888-641-2767 - |
| |
|The PNP exam applicant must be a graduate of an accredited college or university that offers an NLNAC or CCNE accredited formal nursing |
|master’s or doctoral degree program with a concentration in pediatric primary care, acute care or dual primary/acute care as a nurse |
|practitioner. The PNP exam applicant may also be a graduate of a formal post master’s pediatric primary care or acute care nurse practitioner |
|certificate program from an accredited college or university. All information below must be provided. Blank items will invalidate this form. |
|This form must be completed and signed by a Program Director or appropriate designee in order for the form to be valid. Electronic signatures |
|are acceptable. The completed form must be emailed from the program director directly to exam@ or faxed to 301-330-1504. |
|APPLICANT Information (Complete through #6 below then forward to your PNP Program Director) |
| |
|Applicant Name (First, Middle, Last): |
|Last 4 digits of Social Security Number: |
|Email Address: |
| |
|Dual track PNP Primary Care and PNP Acute Care students must document completion of each PNP clinical track. One form will provide |
|verification for both tracks. |
| |
|1. Please select the appropriate PNP Exam |
|Primary Care PNP Exam Acute Care PNP Exam |
| |
|2. Please select the appropriate educational track and enter the degree conferral date. |
|Master’s (MM/DD/YYYY) |
|Post Master’s (MM/DD/YYYY) |
|DNP/Doctoral student(MM/DD/YYYY) |
|Program Information |
| |
|3. Name of School |
| |
|4. Name of Program |
| |
|5. Address of School |
| |
| |
|PROGRAM DIRECTOR (Complete the Below Information using the accreditation dates at the time the student attended the program.) |
| |
|6. Accreditation CCNE NLNAC Both |
| |
|Accreditation Date (MM/YYYY) |
| |
|Expiration Date (MM/YYYY) |
| |
|7. Total number of clinical hours |
|(The National Task Force Criteria for Evaluation of Nurse Practitioner Programs requires a minimum of 500 supervised clinical hours per program|
|track. PNCB highly recommends 600 supervised clinical hours for acute care programs.) |
| |
|8. Dual Primary/Acute Care PNP Program (Check if Yes) |
| |
|9. Complete information for the following courses – if student completed a dual program please complete the course information for both |
|the acute and primary care tracks. |
| |
|Course Name |
|Course Number |
|Course Title |
| |
|Advanced Physiology & |
|Pathophysiology |
| |
| |
| |
|Advanced Pharmacology |
| |
| |
| |
| |
|Advanced Health Assessment |
| |
| |
| |
| |
| |
|Signature of Program Director: |
| |
|Title |
| |
|Phone Number: |
| |
|Email Address: |
| |
|Date (MM/DD/YYYY) |
| |
|This Documentation of PNP Education Form must be submitted directly to the PNCB from the educational institution. |
|Please email this form to exam@ or fax to 301-330-1504. |
|Revised 4/22/2015 |
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related searches
- xfinity homepage for windows 10
- make xfinity my homepage in windows 10
- change homepage to xfinity for windows 10
- set edge homepage to xfinity
- set xfinity as homepage windows 10
- change homepage to xfinity by comcast
- comcast homepage email sign in
- beaumont isd homepage teams
- xfinity homepage download
- ask homepage free download
- ask homepage download
- change homepage to ask